ADVOCACY UPDATE: Lawmakers Push CMS to Finalize Prior Auth Rule

Last week, 294 congressional lawmakers – 233 in the House and 61 in the Senate – sent a letter to the Centers for Medicare & Medicaid Services (CMS) asking the agency to finalize a proposed rule that would streamline and improve transparency of prior authorization processes in Medicare Advantage, Medicaid, CHIP and Qualified Health Plans on the Federally Facilitated Exchanges. This action follows efforts by ASNC's Health Policy Committee to recruit lawmakers to sign on to the letter.  
In March, ASNC sent its own letter to CMS, communicating support for the proposed prior authorization policy changes and asking the agency to strengthen its proposals by requiring shorter processing timeframes and standardization across payers.

The letter sent by lawmakers last week also asks CMS to improve its proposed regulations by – 
  • Establishing a mechanism for real-time prior authorization decisions for routinely approved services;
  • Setting a deadline of 24 hours for Medicare Advantage plans to respond to prior authorization requests for urgently needed care; and
  • Requiring detailed transparency metrics.
Many of the proposals in the rule align with the Improving Seniors' Timely Access to Care Act, which ASNC has made an advocacy priority. Last year, the legislation passed in the House of Representatives but did not receive consideration in the Senate after the Congressional Budget Office (CBO) estimated the bill would cost roughly $16 billion over 10 years due to the additional care that would be provided to seniors. Currently, coverage of such care is most likely being denied but is otherwise medically necessary.

The CBO has said if the final regulations look more like the legislation considered by Congress last year, then the cost of the bill would drop because CMS policy would already be in place.

According to published reports, CMS has said it plans to issue a final rule by December 2025, but sooner if possible. Stay tuned to ASNC for updates.